Data on various process components recruitment, reach, fidelity, satisfaction, and implementation components, i.e., dose delivered and dose received were collected and analysed on two le
Trang 1R E S E A R C H A R T I C L E Open Access
Process evaluation of a participatory ergonomics programme to prevent low back pain and neck pain among workers
Maurice T Driessen1,2, Karin I Proper1,2, Johannes R Anema1,2*, Paulien M Bongers1,2,3, Allard J van der Beek1,2
Abstract
Background: Both low back pain (LBP) and neck pain (NP) are major occupational health problems In the
workplace, participatory ergonomics (PE) is frequently used on musculoskeletal disorders However, evidence on the effectiveness of PE to prevent LBP and NP obtained from randomised controlled trials (RCTs) is scarce This study evaluates the process of the Stay@Work participatory ergonomics programme, including the perceived implementation of the prioritised ergonomic measures
Methods: This cluster-RCT was conducted at the departments of four Dutch companies (a railway transportation company, an airline company, a steel company, and a university including its university medical hospital) Directly after the randomisation outcome, intervention departments formed a working group that followed the steps of PE during a six-hour working group meeting Guided by an ergonomist, working groups identified and prioritised risk factors for LBP and NP, and composed and prioritised ergonomic measures Within three months after the
meeting, working groups had to implement the prioritised ergonomic measures at their department Data on various process components (recruitment, reach, fidelity, satisfaction, and implementation components, i.e., dose delivered and dose received) were collected and analysed on two levels: department (i.e., working group members from intervention departments) and participant (i.e., workers from intervention departments)
Results: A total of 19 intervention departments (n = 10 with mental workloads, n = 1 with a light physical
workload, n = 4 departments with physical and mental workloads, and n = 4 with heavy physical workloads) were recruited for participation, and the reach among working group members who participated was high (87%) Fidelity and satisfaction towards the PE programme rated by the working group members was good (7.3 or higher) The same was found for the Stay@Work ergocoach training (7.5 or higher) In total, 66 ergonomic
measures were prioritised by the working groups Altogether, 34% of all prioritised ergonomic measures were perceived as implemented (dose delivered), while the workers at the intervention departments perceived 26% as implemented (dose received)
Conclusions: PE can be a successful method to develop and to prioritise ergonomic measures to prevent LBP and
NP Despite the positive rating of the PE programme the implementation of the prioritised ergonomic measures was lower than expected
Trial registration: Current Controlled Trials ISRCTN27472278
* Correspondence: h.anema@vumc.nl
1 Body@Work TNO VUmc, Research Center Physical Activity, Work and Health,
VU University Medical Center, van der Boechorststraat 7, 1081 BT
Amsterdam, The Netherlands
Full list of author information is available at the end of the article
© 2010 Driessen et al; licensee BioMed Central Ltd This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
Trang 2The prevalence of low back pain (LBP) and neck pain
(NP) among workers is high [1,2] To prevent or reduce
these symptoms, ergonomic interventions are commonly
applied [3] However, ergonomic interventions appeared
to be most often not effective in the prevention of LBP
and NP [2,4-6] An important reason for finding no
effects on LBP and NP might be due to the inadequate
implementation of ergonomic measures (i.e.,
compli-ance, satisfactions and experiences) and the lack of
using adequate implementation strategies [7]
Participatory ergonomics (PE) is a noted
implementa-tion strategy to develop ergonomic measures from the
bottom up [8-10] According to the stepwise PE method,
ergonomic measures are developed by working groups
(consisting of workers, management, and other
impor-tant stakeholders) [8,10-12] By using this bottom up
approach, the acceptance to use the ergonomic
mea-sures may become more widespread among end-users
(i.e., workers) To inform, educate, and instruct workers
on the PE process, other supportive implementation
strategies, such as distribution of brochures and flyers,
providing training, and capitalising on opinion leaders
are used [13,14] The actual implementation of
ergo-nomic measures is considered as a (possible)
conse-quence of the PE process and can be enhanced by the
use of additional implementation strategies (e.g., use of
opinion leaders)
The effects of PE on the reduction of musculoskeletal
disorders (MSD) have shown to be promising [15-21]
However, it should be noted that most studies on the
effectiveness of PE were of low quality and were
con-ducted in a working population with heavy workloads
Studies directly assessing the prevention of MSD are
rare, especially those using a randomised study design
The only randomised controlled trial (RCT) in the area
of PE and the prevention of MSD has been conducted
by Haukka et al (2008) They showed that PE was not
effective to prevent MSD among kitchen workers [22]
More high-quality studies (RCTs) evaluating the
effec-tiveness of PE are needed Therefore,“The Stay@Work
study” currently investigates the effectiveness of a PE
programme on the prevention of LBP and NP among a
heterogeneous population of workers [23]
In the past years, the conduct of process evaluations
alongside RCTs has been recommended, because they
can facilitate the interpretation of the findings [24] For
example, a process evaluation can shed light on whether
the intervention was delivered as intended (i.e.,
compli-ance, adherence, satisfaction, and experiences) as well as
the success and failures of the intervention programme
[25-28] Moreover, the information obtained from a
pro-cess evaluation can be used to further improve the
intervention [26,29], and to enable the transition of research evidence into occupational health practice [30] Therefore, this study evaluated the process of the Stay@Work PE programme, including the perceived implementation of the prioritised ergonomic measures
Methods
This process evaluation was performed alongside a RCT
on the effectiveness of a PE programme on the preven-tion of LBP and NP among workers, called Stay@Work The Medical Ethics Committee of the VU University Medical Center approved the study protocol Detailed information on the methods, randomisation procedure, and intervention can be found elsewhere [23] The departments of four large Dutch companies (a railway transportation company, an airline company, a univer-sity including its univeruniver-sity medical hospital, and a steel company) were invited to participate in the study The higher management of all companies agreed with the financial and organisational consequences of the inter-vention Based on their main workload, participating departments were classified into: mental, physical, mix mental/physical, or heavy physical departments [31] Within each company, one randomisation pair of two departments with comparable workloads was randomly allocated to either the intervention group (Stay@Work
PE programme) or the control group (no Stay@Work
PE programme)
All workers at the departments of both groups received the baseline questionnaire and watched three short (45 seconds) educative movies about the preven-tion of LBP and NP
The Stay@Work PE programme
In short, the intervention comprised a six-hour working group meeting, in which the steps of the Stay@Work PE programme were followed Each intervention depart-ment had to form a ‘working group’, in which both workers and management participated as members [8,11] Each working group consisted of at least one manager with decision authority, a maximum of eight workers who were a solid representation of the largest and most important task groups at the department If available, an occupational health and safety coordinator was incorporated in the working group as well Working group members had to have worked at least two years
in their current job, worked for more than 20 hours per week at the department, had responsibilities within his/ her own task group, was a role model for his/her co-workers, and was motivated to participate as a member
in the working group [23] During the first meeting, the working group discussed a document containing infor-mation on risk factors on LBP and NP present at the
Trang 3department, which were obtained from the ergonomist
workplace visit (which was mandatory for each
interven-tion department), pictures made by the working group
members, and baseline questionnaire information (step
one) Then, the working group could add other risk
tors of LBP and NP, and judged all mentioned risk
fac-tors as to their frequency and severity Based on the
perceptions of the working group, the most frequent
and severe risk factors were prioritised, resulting in a
top three of risk factors (step two) Subsequently, the
working group held a brainstorming session about
dif-ferent types of ergonomic measures targeting the
priori-tised risk factors, evaluated the ergonomic measures
according to a criteria list considering: relative
advan-tage, costs, compatibility, complexity, visibility, and
fea-sibility within a time frame of three months [32] On a
consensus basis, the working group prioritised the three
most appropriate ergonomic measures (step three)
Finally, the prioritised risk factors and the prioritised
ergonomic measures were written down in an
imple-mentation plan (step four) The impleimple-mentation plan
described for each ergonomic measure which working
group members were responsible for its implementation
Based on their interests in the projects, the prioritised
ergonomic measures were divided among the members
of the working group Working group members who
had a responsibility towards implementation of a
priori-tised ergonomic measure were called the‘implementers.’
At the end of the meeting, the working group was
requested to implement the ergonomic measures (step
five) and was asked whether an appointment for a
sec-ond, optional, meeting was necessary to evaluate or
adjust the implementation process (step six) During the implementation process, all working groups were allowed to ask help from other professionals (i.e., techni-cians, engineers, or suppliers) or services (i.e., equipment
or health services) To improve the implementation pro-cess, two or three working group members from each working group were asked to voluntarily follow a train-ing programme to become a Stay@Work ergocoach In this additional four-hour implementation facilitation training, workers were educated in different implemen-tation strategies to inform, motivate, and instruct co-workers about the prioritised ergonomic measures Moreover, the ergocoaches were equipped with a Stay@-Work toolkit consisting of flyers, posters, and presenta-tion formats about the prioritised ergonomic measures According to the Attitude - Social influence - self-Efficacy (ASE) behavioural change model that was applied during the PE programme, dissemination of information about ergonomic measures may increase worker’s self-awareness of their own behaviour and increase knowledge about possible ergonomic solutions Thus informing workers can be regarded as a first step
in order to induce a behavioural change [13,33]
The process evaluation
An adapted version of the Linnan and Steckler frame-work, which has been recommended to be a useful guide for the conduct of a process evaluation, was used [34,35] Table 1 presents the components that were addressed; recruitment, reach, fidelity, satisfaction, and implementation components (i.e., dose delivered and dose received)
Table 1 Process evaluation components and their definitions
Component Definition
Recruitment - Number of intervention departments that agreed to participate
- Number of working groups formed
- Number of working group members recruited for additional ergocoach training
- Number of workers who responded to the baseline questionnaire
Reach - Number of worksite visits by ergonomist
- Number of working group members who attended working group meeting
- Number of working group members who attended the Stay@Work ergocoach training
Fidelity - The extent to which the steps of the PE programme were delivered as intended
Satisfaction - Satisfaction of working group members towards the prioritised risk factors and ergonomic measures, the ergonomist ’s
competences, and duration of the working group meeting
- Satisfaction of working group members who followed the Stay@Work ergocoach training towards the course leader ’s competences, and the duration of the training
- Satisfaction of workers at the department towards the perceived implemented ergonomic measures and towards the intervention method (PE) that was used to develop the ergonomic measures
Dose
delivered
- Perceived implementation of the ergonomic measures according to the implementers
Dose
received
- Perceived implementation of the prioritised ergonomic measures according to the workers at the departments
- Workplace implementation of the prioritised ergonomic measures according to the workers at the departments
Trang 4Data collection
The process evaluation was conducted for the
interven-tion departments only The PE programme is a complex
intervention, containing components that may affect
dif-ferent levels Therefore, if appropriate, data on the
com-ponents were collected on two levels (see Table 2):
department level (i.e., working group members from
intervention departments) and participant level (i.e.,
workers from intervention departments)
Recruitment
Department level recruitment
The department level was defined as the number of
intervention departments that agreed to participate in
the study and the number of working groups formed
Managers who formed the working group had to send a
list with names of the working group members to the
principal researcher At the end of each working group
meeting, two or three members were recruited for the
additional Stay@Work ergocoach training
Participant level recruitment
The level of the participant was defined as the number
of workers who filled out the baseline questionnaire
Department level reach
At the level of the department,‘reach’ was defined in
two ways First as the number of worksite visits
con-ducted by the ergonomists During a worksite visit, the
ergonomist observed activities or situations that were
considered relevant for LBP and NP Information on the
workplace visits was sent to the principal researcher
Second, reach was defined as the number of workers
that attended the working group meeting and the
num-ber of working group memnum-bers that attended the
Stay@-Work ergocoach training Before the start of each
session, all working group members had to sign a list to
confirm their attendance Reasons for not attending
were registered
Department level fidelity and satisfaction
Directly after finishing the working group meeting, all working group members were asked to report on the components fidelity and satisfaction: at the level of the department,‘fidelity’ was defined as the extent to which the steps of the PE programme were delivered as intended, and was rated on an 1-10 point scale (very bad to very good); at the level of the department, ‘satis-faction’ was rated on an 1-10 point scale (very unsatis-fied to very satisunsatis-fied) and encompassed satisfaction towards the outcomes (risk factors and ergonomic mea-sures prioritised), the ergonomist’s competences, and the duration of the meeting was assessed By using the same components (fidelity and satisfaction) and mea-sures (1-10 scale), the Stay@Work ergocoach training was evaluated
Participant level satisfaction
At the level of the participant, satisfaction could only be measured among workers who perceived at least one ergonomic measure as implemented By using an 1-10 point scale (very unsatisfied to very satisfied), satisfac-tion with the perceived implemented ergonomic mea-sure(s) was assessed; likewise, satisfaction with the intervention method (PE) used to develop ergonomic measures was measured These workers were also asked
on how they took notice of the supportive implementa-tion measures (i.e., e-mail/poster/flyer)
Implementation Department level dose delivered
Four months after finishing the working group meeting, the implementers– working group member(s) responsi-ble for the implementation of one or more prioritised ergonomic measure(s)– received a short questionnaire Implementers were asked whether the prioritised ergo-nomic measures for which he/she was responsible for were realised (implemented) at the department as
Table 2 Process evaluation data collection: main levels and methods
Component Department
level
Participant level
Data collection tool Recruitment X X Checklist and baseline questionnaire
Fidelity X 1 to 10 scale (very bad to very good)
Satisfaction X X 1 to 10 scale (very unsatisfied to very satisfied)
Dose
delivered
X Questionnaire assessing for each prioritised ergonomic measure the perceived implementation
(yes/partly/no) Dose
received
X Questionnaire assessing for each prioritised ergonomic measure the:
1) Perceived implementation (yes/no/don ’t know) 2) Workplace implementation (yes/no)
Trang 5described in the original implementation plan The
per-ceived implementation was assessed separately for each
ergonomic measure For each ergonomic measure, the
implementers could choose from three answer
categories:
1 yes, implemented: the prioritised ergonomic
mea-sure was realised as described in the implementation
plan
2 yes, partly implemented
3 no, not implemented: the prioritised ergonomic
measure was not realised as described in the
implemen-tation plan
This method enabled the investigators to calculate for
each ergonomic measure of interest a percentage of the
perceived implementation The implementation
percen-tage was derived by summing the frequencies of each of
the three answer categories (yes, implemented/yes,
partly implemented/no, not implemented) By summing
all implementation percentages and dividing by the total
number of prioritised ergonomic measures, an overall
implementation percentage for all departments could be
calculated
Participant level dose received
All information on the participant level was obtained
from workers who responded to the six-month
follow-up questionnaire, and addressed information on:
1 The perceived implementation of the ergonomic
measures was measured by means of a separate question
that asked workers whether the prioritised ergonomic
measure was implemented by the working group at
their department For each ergonomic measure, three
answers were possible: yes/no/don’t know By using a
procedure similar to the one for dose delivered, an
over-all perceived implementation percentage was calculated
2 The workplace implementation was assessed among
those workers who perceived an ergonomic measure as
implemented By means of another question they were
asked whether the ergonomic measure was applicable to
their workplace (yes/no) The percentage of
implemen-ted measures at their workplace was derived by dividing
the number of‘yes actually implemented’ by the number
of‘yes perceived as implemented’
Results
Recruitment and reach
Department level
In total, 37 departments were included in the
randomi-sation procedure with 19 departments randomised to
the intervention group Among the intervention
depart-ments, 10 departments were characterised by mental
workloads, one department had a light physical
work-load, four departments had mixed workloads (physical
and mental), and four departments had heavy physical
workloads
One department with a mixed workload (n = 103 workers) dropped out of the study due to a sudden reor-ganisation, and no working group was formed at that department Further, as the department managers of four departments with a ‘mental workload’ were not able to select a sufficient number of workers to partici-pate in the working group, it was decided to form two working groups instead of four Thus, out of 18 depart-ments, 16 working groups were formed In total, 113 working group members were invited to participate All working groups held a working group meeting, which was attended by 98 working group members (87%) Of the 15 non-attending members six were on sick leave, seven were too busy, one had a regular day off, and one was no longer working at the department
Eight Stay@Work ergocoach training sessions were held and were attended by 40 working group members The number of members per working group that fol-lowed the training varied from one to six
Participant level
The baseline questionnaire was sent to 5,695 workers, of whom 3,232 (57%) responded A total of 185 workers did not meet the inclusion criteria for data analyses, which were: aged between 18 years and 65 years; no cumulative sick leave period longer than four weeks due
to LBP or NP in the past three months before the start
of the intervention; and not pregnant [23] Hence, at baseline 3,047 (53%) workers were included Among them, 1,472 workers were working at intervention departments Compliance to watching the movies on LBP and NP prevention in the intervention group was 67%
Fidelity and satisfaction Department level
Six trained ergonomists conducted the worksite visits (n = 18) and guided the working group meetings The number of working groups that each ergonomist guided varied from one to five
All 16 working groups completed the first working group meeting according to the study protocol and developed an implementation plan Three working groups, all characterised by heavy physical workloads, planned the second (optional) working group meeting Working group members (n = 98) rated the quality of the PE steps performed between 7.32 (SD 1.02) and 7.59 (SD 0.99), and were satisfied with the risk factors and ergonomic measures prioritised (7.30, SD 1.15), the ergonomist’s competences (7.70, SD 0.92) and the six-hour duration of the meeting (7.06, SD 1.30)
In total, 40 working group members (25 men and 15 women) followed the Stay@Work ergocoach training and were positive about the quality of the training (7.67,
SD 0.48), were satisfied with the course leader’s
Trang 6competences (8.03, SD 0.70), and with the four-hour
duration of the training (7.53 (SD 1.15))
Participant level
Workers at the departments who perceived at least one
of the ergonomic measures as implemented were
informed about the ergonomic measure(s) by poster/
flyer/e-mail (55%), by a presentation provided by a
working group member (41%), or by their supervisor
(24%) Workers rated their satisfaction towards the
ergo-nomic measures as prioritised by the working group
(5.72, SD 2.39) and the method (PE) used to develop
and prioritise the ergonomic measures (5.59, SD 2.29)
In case the ergonomic measures were implemented at
their workplace, satisfaction towards the ergonomic
measures was 6.02 (SD 2.31) For the method used to
develop and prioritise the ergonomic measures their
satisfaction was 5.82 (SD 2.23)
Implementation
Department level: dose delivered
In total, the working groups prioritised 66 ergonomic
measures The number of ergonomic measures per
working group varied from three to six The 66
priori-tised ergonomic measures were classified by two
researchers independently from each other into three
categories: individual, physical, and organisational
ergo-nomic measures [36] The classification resulted in: 32
individual, 27 physical, and 7 organisational ergonomic
measures (see Table 3)
To investigate whether the 66 prioritised ergonomic
measures were actually implemented at the departments,
the 81 implementers were sent a short questionnaire A
total of 65 of the implementers responded (80%) From
the questionnaire, it appeared that the implementation
status of three prioritised ergonomic measures was
unknown (n = 1 individual, n = 2 physical) Therefore,
this study evaluated the perceived implementation of 63
prioritised ergonomic measures (n = 31 individual;
n = 25 physical; n = 7 organisational)
Implementers reported that altogether 34% of the prioritised ergonomic measures was implemented, 26% was partly implemented, and 40% was not implemented
at the 18 departments From the answers on the ques-tionnaire, it was shown that within working groups implementers sometimes disagreed on the implementa-tion status of the prioritised ergonomic measure That
is, one implementer perceived the measure as imple-mented, whereas another implementer within the same working group perceived the measure as not implemen-ted Table 4 presents the percentages of the perceived implementation stratified by type of ergonomic measure and department workload In general, highest imple-mentation rates were found for individual ergonomic measures (53%), and lowest implementation rates for organisational ergonomic measures (28%) At the light physical workload department, the implementation was 100%, but these results were obtained from only one department Organisational ergonomic measures were most common at the departments with a mental work-load and were in most cases‘partly’ implemented (47%) Departments with a heavy physical workload most often prioritised physical ergonomic measures (n = 12), but the perceived implementation was low (16%) Depart-ments with a mixed workload, and departDepart-ments with a mental workload, most often prioritised individual ergo-nomic measures (n = 11) The perceived implementation between these two department types, however, varied largely (26% to 79%)
Participant level: dose received
According to the 833 workers who responded to the per-ceived implementation questions in the six-month fol-low-up questionnaire, 26% perceived the ergonomic measures as implemented, 36% as partly implemented, and 38% as not implemented at the departments Table 5
Table 3 Types and targets of the prioritised ergonomic measures (n = 66)
Training in working techniques, (i.e., lifting technique) 3 Personal protective equipment (i.e., kneepads) 1 Physical (n = 27) Ergonomic redesign and/or workstation modifications 18
Manual handling aids (i.e., lifting devices) 5
Develop protocol to improve worker ’s health 1
Trang 7Table 4 Perceived implementation of the prioritised ergonomic measures according to the implementers (n = 65) Ergonomic measures perceived as implemented Type of ergonomic measure
All departments (n = 18) Individual (n = 31) Physical (n = 25) Organisational (n = 7)
Mental workload departments (n = 10) Individual (n = 11) Physical (n = 7) Organisational (n = 5)
Light physical workload departments (n = 1) Individual (n = 1) Physical (n = 2) Organisational (N/A)
Mixed workload departments (n = 3) Individual (n = 11) Physical (n = 4) Organisational (N/A)
Heavy physical workload departments (n = 4) Individual (n = 8) Physical (n = 12) Organisational (n = 2)
N/A = not applicable
Table 5 Perceived implementation of the prioritised ergonomic measures according to the workers at the
departments (n = 833)
Ergonomic measures perceived as implemented Type of ergonomic measure
All departments (n = 18) Individual (n = 31) Physical (n = 25) Organisational (n = 7)
Mental workload departments (n = 10) Individual (n = 11) Physical (n = 7) Organisational (n = 5)
Light physical workload departments (n = 1) Individual (n = 1) Physical (n = 2) Organisational (N/A)
Mixed workload departments (n = 3) Individual (n = 11) Physical (n = 4) Organisational (N/A)
Heavy physical workload departments (n = 4) Individual (n = 8) Physical (n = 12) Organisational (n = 2)
Trang 8presents the percentages of the perceived implementation
of the ergonomic measures stratified by type of
ergo-nomic measure and department workload Among the
26% of the workers who perceived the ergonomic
mea-sures as implemented at the departments, the ergonomic
measure was in 69% of the cases implemented at their
workplace
Discussion
The Stay@Work study investigated whether PE is an
effective method to prevent LBP and NP among
work-ers The aim of the current study was to evaluate the
process of the Stay@Work PE programme
implementa-tion including the perceived implementaimplementa-tion
effective-ness of the prioritised ergonomic measures
The results of this process evaluation showed that
almost all department managers formed a working
group and that a meeting was held with all working
groups Attendance rates of the working group meetings
were good, and all working groups were successful in
developing an implementation plan with prioritised risk
factors for LBP and NP and prioritised ergonomic
mea-sures to prevent LBP and NP Working group members
were positive about the quality of the PE steps
per-formed during the meeting, meeting duration, and the
prioritised ergonomic measures These opinions were
not shared among the remaining workers at the
depart-ments Attendance rates of the Stay@Work ergocoach
training and the quality of the training were good
Workers at the departments were not satisfied with the
implementation strategy used Dissatisfaction may have
occurred because workers at the departments were kept
blind as to the study design and were thereby only
mar-ginally informed about the PE programme content and
its aims It is plausible that workers at the departments
did not link the prioritised ergonomic measures to the
PE programme and were therefore not sufficiently able
to rate their satisfaction with the used method
More-over, dissatisfaction among workers might have occurred
because they were asked to report on the
implementa-tion of ergonomic measures that were not (always)
applicable to their workplace However, workers’
satis-faction towards both the prioritised ergonomic measure
and the method that was used to develop the ergonomic
measures increased somewhat when the ergonomic
measures were implemented at their workplace
Overall, it can be concluded that the Stay@Work PE
programme is a successful and feasible strategy to
develop an implementation plan with prioritised risk
factors for LBP and NP and prioritised ergonomic
mea-sures to prevent LBP and NP It is more difficult,
how-ever, to draw conclusions regarding the implementation
rates as there is no cut-off point to determine whether
implementation was successful or has failed Regarding
the prevention of LBP and NP it can be suggested that every (extra) ergonomic measure implemented might be profitable [3,37,38], even when perceived implementa-tion rates of 34% and 26% are derived Future research should investigate whether the implementation rates found in this study are sufficient to reduce workload and thereby reduce LBP and NP prevalence among workers
The perceived implementation rates found in our study differed from other studies on PE For example Haukka et al (2008) conducted a RCT on PE and MSD prevention and reported a perceived implementation rate of 80% (402 ergonomic changes) [22,39], although
it remained unclear how they assessed whether an ergo-nomic measure was implemented There are several explanations for the different implementation rates found in our study compared to other PE studies like the Haukka study
In our study, individual ergonomic measures were prioritised most often, especially among departments with a mixed workload The choice to prioritise and implement individual ergonomic measures seemed plau-sible, since the ergonomic measures were evaluated according to a set of common implementation criteria: low initial costs, not complex, compatible, visible, and feasible within three months In line with other studies
on PE, physical ergonomic measures were also priori-tised frequently However, other studies also found higher frequencies on organisational ergonomic mea-sures [16,17,22,39,40] The reason why fewer organisa-tional ergonomic measures were prioritised in this study may be a result of the implementation criteria that were probably less applicable to evaluate organisational ergo-nomic measures In addition, the implementation of physical or organisational measures is more complex, expensive, and time consuming to perform compared to individual ergonomic measures [30]
Another possible explanation involves the inconsistent answers on the implementation status of the prioritised ergonomic measure (yes/no/partly implemented) For example, within the same working group, two out of the five implementers reported that the prioritised ergo-nomic measure was implemented, whereas the remain-ing implementers reported that the ergonomic measure was not implemented Such inconsistencies often made
it impossible for the researchers to decide whether a measure really was implemented More knowledge about the implementers’ reasons for choosing a certain implementation status may have helped the researchers
to make decisions about the implementation status of the prioritised ergonomic measures However, due to the purpose of this study, no information on such rea-sons was collected Furthermore, inconsistency may have been caused by the high number of ‘yes, partly
Trang 9implemented’ answers In our questionnaire that was
sent to the implementers, we did not specifically define
the term ‘yes, partly implemented’ However, from the
information obtained from the questionnaire we suspect
that some implementers chose‘yes, partly implemented’
when they discovered that it was more beneficial to
implement a prioritised ergonomic measure for only a
subgroup of workers rather than for all workers at the
intervention department Other implementers appear to
have chosen ‘yes, partly implemented’ when the
imple-mentation of the prioritised ergonomic measure was in
progress but had not been completely realised yet For
example, in case of the implementation of a lifting
device, implementers ordered the device; however, the
lifting device was not yet being used at the workplace
Finally, although several explanations for the modest
implementation have been discussed, it is possible that
other unmeasured factors might have occurred during
the implementation period (e.g., hierarchy, poor
manage-ment support, lack of assistance, or financial problems)
thereby hampering implementation [41] For example, it
is plausible that a lack of financial resources may have
hampered the implementation of ergonomic measures
This is because most working groups were conducted in
2008 – a time when many Dutch companies
experi-enced the consequences of the international financial
downturn Moreover, different implementation factors
may be present or absent at different stakeholder levels
(i.e., individual professional, worker, societal, or
organi-sational level) [14] More in-depth knowledge on
imple-mentation factors and their stakeholder level can help
researchers to improve ergonomic interventions
There-fore, to further improve the implementation of this or
future PE programme(s), it may be helpful to explore
what factors hampered or facilitated the implementation
of ergonomic measures
Strengths and weaknesses of the process evaluation
No other study implemented PE on such a large scale
and among departments with different type of
work-loads Furthermore, this process evaluation study
col-lected extensive data on the perceived implementation
In doing so, this study attempted to estimate the
effi-ciency of the PE programme and the implementation
strategies The existing literature suggests that the use
of informational material alone is not sufficient to
induce a behavioural change (i.e., use of ergonomic
mea-sures) More active strategies such as toolkits and local
opinion leaders should be used to disseminate
informa-tion [13] Therefore, a strength of this study was that
not only informational materials but also ergocoaches
(opinion leaders) trained to inform, motivate, and
instruct their co-workers on the ergonomic measures
Further, data were collected from different stakeholders
at different levels which provided a better understanding
of how the different stakeholders experienced the PE programme and the implementation strategies
A weakness of this study is that selection bias may have occurred because not all implementers and not all work-ers at the department responded to their questionnaires Furthermore, the accuracy of the method that was used
to measure implementation is debatable All workers at the department were asked whether the prioritised ergo-nomic measures were implemented Due to the variety of task groups within departments, it may be that some workers were asked to report on implementations that were not meant for their workplace The same goes for the implementers, who during the implementation of the ergonomic measures may have discovered that a priori-tised ergonomic measure was more beneficial for a sub-group of workers rather than for the whole department This may have led to misinterpretations of the concept of implementation and may have resulted in inconsistent answers on the questionnaires A possible solution to overcome such inconsistencies and to increase the valid-ity of the answers provided by the implementers is to arrange control visits by an ergonomist [42] Finally, the role of the ergonomist in the current study was restricted
to guiding the working group meeting In line with the
PE literature [43], working group members themselves were responsible for the implementation of the priori-tised ergonomic measures Although working group members were allowed to seek help from other profes-sionals during the implementation period, no informa-tion on which professionals were consulted was collected It is, however, plausible that more assistance and cooperation from the ergonomist, other professionals (i.e., suppliers, technicians, and purchase) and the man-agement to realise implementation, might indeed have led to higher implementation rates
Summary
The results of this process evaluation showed that PE can be a feasible and successful strategy to develop an implementation plan with prioritised risk factors for LBP and NP and prioritised ergonomic measures to pre-vent LBP and NP Moreover, recruitment, reach, fidelity, and satisfaction towards the PE programme were good The same was found for the Stay@Work ergocoach training Despite the positive rating of the PE pro-gramme and the ergocoach training, the implementation
of the prioritised ergonomic measures was lower than expected Further research is needed to develop and test ways to more optimally implement PE programmes in order to reduce work-related injuries and to promote worker well-being
Trang 10This study is granted by: The Netherlands Organisation for Health Research
and Development (ZonMw).
Author details
1 Body@Work TNO VUmc, Research Center Physical Activity, Work and Health,
VU University Medical Center, van der Boechorststraat 7, 1081 BT
Amsterdam, The Netherlands.2Department of Public and Occupational
Health, EMGO Institute for Health and Care Research, VU University Medical
Center, van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands.
3 TNO Quality of Life, Polarisavenue 151, 2132 JJ, Hoofddorp, The
Netherlands.
Authors ’ contributions
All authors contributed to the design of the study MTD is the principle
researcher and was responsible for the data collection and data analyses.
JRA contributed to the conception and the design of the study and
coordinated the study KIP, JRA, PMB, and AJvdB supervised the study All
authors contributed to writing up of this paper and approved the final
manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 18 November 2009 Accepted: 24 August 2010
Published: 24 August 2010
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